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Palliative Inotrope TherapyA Narrative Review

Educational Objective
To improve understanding of palliative inotrope therapy for patients with heart failure.
1 Credit CME

Importance  The number of patients living with end-stage heart failure is steadily growing, and ambulatory intravenous inotropic support is increasingly offered as a palliative therapy. However, the optimal ways to initiate, manage, and discuss the risks and benefits of palliative inotropes in the current era of heart failure care are unclear.

Observations  The initiation of palliative inotropes requires an understanding of clinical, psychosocial, and economic factors, as well as the changing risk-to-benefit calculus. While earlier studies suggested that outpatient inotrope therapy provided symptomatic benefit at the expense of reduced survival, recent data suggest that the survival of patients receiving chronic inotropes may be improving over time, perhaps owing to the use of implantable cardioverter defibrillators, concurrent guideline-directed medical therapy, or lower doses of inotropes. The use of heart failure therapies, such as β-blockade, among patients receiving palliative inotropes is controversial but may be appropriate in select situations.

Conclusions and Relevance  The role of palliative inotropes is changing in tandem with advances in chronic heart failure care. However, there remains a profound lack of data and guidance on the effect of palliative inotropes on quality of life and mortality and little consensus on how this therapy can be optimally used in contemporary practice. This review provides a framework for the prescription and management of palliative inotropes, including a discussion of potential risks and benefits and a roadmap for how to initiate, maintain, and wean them.

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Article Information

Corresponding Author: Haider J. Warraich, MD, Division of Cardiology, Department of Medicine, Duke University School of Medicine, 2301 Erwin Rd, DUMC 3485, Durham, NC 27713 (haider.warraich@duke.edu).

Accepted for Publication: May 3, 2019.

Published Online: July 3, 2019. doi:10.1001/jamacardio.2019.2081

Author Contributions: Drs Chuzi and Warraich had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Chuzi, Allen, Warraich.

Drafting of the manuscript: Chuzi, Warraich.

Critical revision of the manuscript for important intellectual content: Allen, Dunlay, Warraich.

Administrative, technical, or material support: Chuzi, Warraich.

Supervision: All authors.

Conflict of Interest Disclosures: Dr Allen reports personal fees from Amgen/Cytokinetics, ACI Clinical, Boston Scientific, and Janssen Pharmaceuticals during the conduct of the study and grants from the American Heart Association, the National Institutes of Health, and Patient-Centered Outcomes Research Institute outside the submitted work. No other disclosures were reported.

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